Symptom of Endometriosis: Infertility and Pregnancy Complications

Endometriosis is often associated with, or causes, infertility. It has been estimated that 20-50% of women with infertility are diagnosed with endometriosis, however, not every woman with endometriosis will be infertile.1,2 Infertility is the inability to become pregnant or carry a baby to term, however, endometriosis does not always cause complete infertility. In some cases, endometriosis may decrease a woman’s chances of getting pregnant, however, pregnancy is still possible (subfertility). In other cases, a woman’s fertility may not be affected at all.

In addition to having an association with infertility, research suggests that women with endometriosis may also have a higher risk of developing pregnancy-related complications. These complications include, but are not limited to, delivering preterm, undergoing a caesarean section (C-section), experiencing pre-eclampsia (high blood pressure and protein in the urine that develops later in pregnancy), placental complications, miscarriage, ectopic pregnancy, uterine rupture, bowel perforation, and bleeding during pregnancy or after birth.2-6

Why are infertility and pregnancy complications linked to endometriosis?

Since endometriosis commonly affects the female reproductive system and structures surrounding the uterus, it makes sense that fertility and pregnancy may be affected. Regarding fertility issues, in some cases, the cause may be obvious, such as scarring that blocks the fallopian tubes or that has impacted the structure of key reproductive organs. In other cases, though, the cause of infertility or decreased fertility may not be obvious. Some common theories on how endometriosis might impact fertility are scarring and distortion of anatomy, immune system-related issues that cause the body to mistakenly attack a developing fetus, and developmental anomalies or malformations of the uterus or other structures in the female reproductive system (such as developing an abnormally shaped uterus).1-5

The relationship between pregnancy complications and endometriosis is not as well understood, however, it may be due to several of the same proposed factors that contribute to infertility in endometriosis. Due to advancements in fertility-enhancing treatment options, and a growing understanding of endometriosis, more women with the condition are getting pregnant than ever before. Because of this, more research is currently ongoing to further understand these associations. However, current research suggests that the most severe complications are often associated with deep-infiltrating endometriosis more often than superficial endometriosis.2,6,7

How is infertility diagnosed or evaluated?

Women who are having difficulties conceiving a child can visit a reproductive endocrinologist to receive fertility testing. Common tests utilized to assess a woman’s fertility include the following:

Imaging exams of the uterus or surrounding structures (such as a pelvic ultrasound or hysterosonography of the uterus)

Ovulation testing

Ovarian reserve testing to assess the quantity and quality of a woman’s eggs

Hysterosalpingogram (which utilizes X-ray contrast to monitor fluid flow between the fallopian tubes and uterus, as well as detects uterine abnormalities-also called HSG)

Genetic testing

Laparoscopy or hysteroscopy (procedures where small viewing scopes are inserted into the abdomen via minimally invasive surgery or into the vagina to assess the structure of the reproductive system)8-10

All of the above tests look for abnormalities in ovulation, hormonal regulation, egg viability, and structure of the reproductive system to determine if there is an issue preventing or decreasing the chances of pregnancy. It’s also important to note that infertility or fertility issues are not only exclusive to women. Men can also be infertile or have fertility-reducing conditions and can visit a reproductive endocrinologist for fertility testing as well.

Treatment for infertility

There are several potential treatment options for women experiencing infertility or reduced fertility. The most appropriate treatment for a woman experiencing these issues will be dependent on a variety of factors, including her age, personal preferences, financial situation, and underlying cause of infertility or reduced fertility. Some of these potential treatment options for women include:

Fertility medications: Fertility medications are typically intended for use by women who have an ovulation-related issue. These drugs are used to stimulate the hormones responsible for initiating ovulation or block hormones that are preventing ovulation. Some of these medications include clomiphene (Clomid), letrozole (Femara), gonadotropins (Repronex, Menopur, Gonal-F, Follistim, Bravelle, Ovidrel, Pregnyl, Novarel), metformin (Glucophage), and bromocriptine (Cycloset).

Intrauterine insemination (IUI): A procedure in which sperm are delivered into the uterus via a catheter to increase the chances of sperm cells meeting the ovulated egg.

Assisted reproductive technology: An example of an assisted reproductive technology is in vitro fertilization, where eggs are removed from the ovaries, fertilized in a laboratory by sperm cells, and then transferred into the uterus.9,10

How are pregnancy complications diagnosed or evaluated?

There are a wide variety of complications that can happen during pregnancy. Many of these may be the result of another underlying condition or due to the mother’s age, weight, or diet. Additionally, the development of an infection can also affect pregnancy, as well as potential compounds in certain medications. Sometimes, the cause of a pregnancy complication may be unknown. One of the most effective ways to prevent pregnancy complications, or to detect them early and receive appropriate care, is to visit your healthcare provider regularly. Your doctor can perform scans and other tests at various points during your pregnancy to evaluate your health, as well as your baby’s health. In addition to regularly visiting your provider, it is also important to watch for signs of a pregnancy complication on your own. Signs of a potential complication include, but are not limited to:

Bleeding from the vagina

Leaking fluid from the vagina

Fever or chills

Vision difficulties or feelings of dizziness

Severe nausea or vomiting

Pain or cramping in the abdomen

Pain or burning when urinating

Experiencing severe headaches

Experiencing sudden swelling

Feeling less movement from your baby in the third trimester

Experiencing mood swings or self-harming thoughts or behaviors11

Treatment for pregnancy complications

Treatment for a pregnancy complication varies from condition to condition. Some pregnancy complications such as infections, high blood pressure, or anemia may require medications. Gestational diabetes mellitus may require a woman to change her diet and exercise patterns during pregnancy. Other conditions may require a woman to deliver preterm, or to undergo a C-section. If you are diagnosed with a pregnancy complication, ask your doctor or healthcare provider what the treatment options are for your specific situation.12

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European Society of Human Reproduction and Embryology. Women with Endometriosis Need Special Care During Pregnancy to Avoid Risk of Premature Birth. EurekAlert: American Association for the Advancement of Science. https://www.eurekalert.org/pub_releases/2009-07/esfh-wwe063009.php. Published July 1, 2009. Accessed March 29, 2018.

Maindiratta B, Lim BH. Pregnancy after endometriosis: A new challenge? BJOG: An International Journal of Obstetrics and Gynaecology. 24 Jan 2017; 124(3). Available from: https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.13979. Accessed March 29, 2018.

How is Infertility Diagnosed? National Institutes of Health: Eunice Kennedy Shriver National Institute of Child Health and Human Development. https://www.nichd.nih.gov/health/topics/infertility/conditioninfo/diagnosed. Published January 31, 2017. Accessed March 29, 2018.

Pregnancy Complications. Office on Women's Health, U.S. Department of Health and Human Services: Womenshealth.gov. https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/pregnancy-complications. Published February 9, 2018. Accessed March 29, 2018.

Pregnancy Complications. Centers for Disease Control and Prevention. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregcomplications.htm. Published June 17, 2016. Accessed March 29, 2018.